BANNER HEALTH BANNER BAYWOOD MEDICAL CENTER Mesa, AZ DEPARTMENT OF SURGERY RULES AND REGULATIONS

Transcription

1 BANNER HEALTH BANNER BAYWOOD MEDICAL CENTER Mesa, AZ DEPARTMENT OF SURGERY RULES AND REGULATIONS ARTICLE I AUTHORITY The Banner Baywood Medical Center Department of Surgery ("Department") is organized as specified in the Medical Staff Bylaws, and these Rules and Regulations are adopted pursuant to Bylaws Sections 14.2 and ARTICLE II ORGANIZATION OF THE DEPARTMENT A. Officers Department officers shall be the department chair and vice chair. 1. Chair. (a) (b) Qualifications. The Department chair shall be an Active Staff member who is qualified by training, experience and demonstrated ability for the position and who has indicated a willingness to serve. Election. As necessary, at its July meeting, the Department Committee shall select one or more members qualified to be chair and forward their names to the MEC, which shall approve or modify the slate of nominees and present the ballot to the Staff. The Department s active Staff members may submit additional qualifying nominees to the Medical Staff Office at least ten (10) days before the official ballot is mailed and the election completed consistent with Bylaws , 13.4, 13.5, 13.6, and Disclosure of Conflicts. All candidates for chair, vice chair and committee members must disclose to the MEC material financial and personal interests that might potentially conflict with Medical Staff and Departmental responsibilities (Bylaws 6.8). 3. Vice Chair. The Department vice chair shall be an Active Staff member elected by the Department at its January meeting. 4. Terms, Vacancies, Removal. The terms of the chair and vice chair shall be two years; vacancies and removal shall be consistent with Bylaws Article 14. B. Department Committee. The Department Committee shall be appointed by the chair subject to the approval of the Medical Staff President. The Committee shall consist of at least four Active Staff members, one of whom need not be a Department member. C. Subcommittees. Subcommittees may be appointed by the chair as deemed necessary to carry out specific functions, subject to the approval of the Department Committee. 1. Peer Review Subcommittee. The PRS reviews and assigns a Peer Review Standard to those cases referred for review. D. Sections: Sections of special interest may be organized as provided in the Medical Staff Bylaws. ARTICLE III MEMBERSHIP A. Physician Membership. Membership in the Department shall be limited to: 1. physicians who are certified by one of the following boards:

2 a. American Board of: 1. Surgery 2. Colon and Rectal Surgery 3. Neurological Surgery 4. Ophthalmology 5. Orthopedic Surgery 6. Otolaryngology 7. Pediatric Surgery 8. Plastic Surgery 9. Surgical Critical Care 10. Urology 11. Vascular Surgery b. American Osteopathic Board of: 1. Surgery (General) 2. Neurological Surgery 3. Orthopedic Surgery 4. Plastic and Reconstructive Surgery 5. Urological Surgery 6. General Vascular Surgery 7 Proctology 8. Ophthalmology and Otorhinolaryngology c. the Royal College of Physicians and Surgeons (Canada) in their declared surgical specialties; or 2. dentists who are certified by one of the specialty boards approved by the ADA: American Board of Oral and Maxillofacial Surgery American Board of Pediatric Dentistry American Board of Periodontology; or 3. physicians and dentists who are qualified (eligible) to sit for the certifying exam(s) of one of the above listed boards. Such individuals must become certified within 6 years of successful completion of residency or fellowship training. Failure to become certified will be grounds for termination of membership on the Active, Courtesy and Consulting Staffs. B. Affiliate Membership. Affiliate membership is limited to podiatrists who: 1. are certified by the American Board of Podiatric Surgery (ABPS) in either foot surgery or foot and ankle surgery; or 2. are "board-qualified" as defined by ABPS. ARTICLE IV FUNCTIONS OF THE DEPARTMENT In accordance with the Bylaws and for the purposes of reducing morbidity and mortality and for the improvement of the care of patients in the hospital, the Department of Surgery shall supervise, review and evaluate all general and sub-specialty surgical practice in the Hospital, except that which falls under the jurisdiction of the Obstetrics and Gynecology Department, including, vascular surgery, general surgery, neurosurgery, ophthalmology, orthopedic surgery, otorhinolaryngology, plastic and reconstructive surgery, urology, podiatry and dentistry, making its recommendations to the MEC. ARTICLE V DUTIES OF THE DEPARTMENT COMMITTEE The Department Committee shall meet regularly to fulfill its duties. A. Privileging Criteria. The department committee shall establish and periodically update its criteria and other requirements for granting privileges, including education, training, performance and supervision.

3 B. Credentialing. The department committee shall examine every completed application for privileges, appointment and reappointment to determine whether the applicant meets all the necessary qualifications. It shall report its conclusions and recommendations to the Credentials Committee, together with the basis for its conclusions and recommendations. It may require a personal interview with any applicant. C. Monitoring Individual Practitioners. The department committee shall monitor and evaluate the professional practices of any individual practitioner exercising privileges granted by the Department. The majority of the department committee members present at any regular or special meeting will: 1. establish terms and conditions as the department committee deems reasonable, for the safe exercise of privileges, which terms may include a requirement that the affected practitioner give advance notice, where possible, of all patient admissions; 2. establish the number and type of cases to be monitored and monitor the practitioner's cases accordingly; 3. submit for MEC review any program of monitoring, other than Provisional Staff appointees, which exceeds six (6) consecutive months. In its discretion, the MEC may continue, modify or terminate the monitoring program. 4. determine the appropriateness of utilizing both monitoring and Corrective Action, as provided in the Bylaws, which are not mutually exclusive. D. Department Performance Oversight. The department committee shall review and analyze, on a peer group (aggregated) basis, the clinical work of the department. It will: 1. participate in the evaluation and implementation of the Hospital's Quality Management and Utilization Management Programs by adopting and keeping up-to-date the department's Quality Improvement Plan (QIP) and requesting from the hospital's QM Department data that shows the impact of departmental and hospital initiatives and processes on the quality of the Department's performance. 2. conduct such reviews no less than four (4) times per year, considering selected deaths, unimproved patients, patients with infections, complications, possible errors in diagnosis and treatment, and other data that the Committee believes to be important. The Surgery Department shall conduct comprehensive review for justification of all surgery performed whether tissue was removed or not and for the acceptability of the procedure chosen. 3. submit a report in the monthly meeting minutes to the Executive Committee, detailing such departmental analysis of patient care. E. ER-Call. The department provides for coverage of the ER by the Department's members as follows: 1. General Surgery/General Surgery Trauma. Those under contract take call consistent with the terms of their contract(s). General Surgery Call includes Trauma Call. General Surgery and General Surgery Trauma Call are a combined call, and the On-Call Physician is required to cover both General Surgery and General Surgery Trauma. 2. Ophthalmology. Those under contract take call consistent with the terms of their contract(s). 3. Orthopedic Surgery/Orthopedic Surgery Trauma. Those under contract take call consistent with the terms of their contract(s). Orthopedic Surgery Call includes Trauma Call. Orthopedic Surgery and Orthopedic Surgery Trauma Call are a combined call, and the On-Call Physician is required to cover both Orthopedic Surgery and Orthopedic surgery Trauma. 4. Plastic Surgery. No call. 5. Podiatry. Daily ER-call is voluntary. 6. Urology. Call is voluntary for Active and Provisional Urology staff. 7. Hand Surgery. Call is voluntary for Active and Provisional Hand surgeons.

4 F. Allied Health Professionals. The department committee shall establish criteria for allied health professionals to practice within the Department including, but not limited to RN First Assists, Certified First Assists, Physician Assistants, Nurse Practitioners and Surgical Assistants. ARTICLE VI RESPONSIBILITIES OF THE DEPARTMENT CHAIR The Chair shall be responsible for: A. preparing all meeting agendas in order to ensure that the Department Committee takes action to fulfill each of its duties listed in Art. 5above. B. annually reviewing - with the Department Committee - all duties and responsibilities stated in these Rules and pertinent provisions of the Medical Staff's General Rules - to ensure implementation and enforcement, and to recommend deletions and additions to reflect current responsibilities. C. ensuring that individual Department members comply with their patient-care responsibilities described in the Medical Staff General Rules ("Hospital Practice Manual"). D. establishing together with medical staff and administration, the type and scope of surgery services as well as the space and other resources required to meet the needs of the Department's patients and the hospital; E. Recommending clinical privileges for each department member, and applicants, approving and withdrawing temporary privileges as indicated; F. monitoring the professional performance of all individuals with clinical privileges in the department; and serving, when requested, in an advisory capacity on the Practitioner Health Committee when it reviews a member of this department. G. continuously assessing and improving the quality of care and services provided in the department; H. coordinating and integrating intradepartmental and interdepartmental services; I. recommending a sufficient number of qualified and competent persons to provide care or service; J. determining and recommending the qualifications and competence of physician-supervised Allied Health Professionals who provide patient care services; K. requesting and/or implementing quality control programs as appropriate; L. ensuring new-practitioner orientation and continuing education of all physicians and allied health professionals in the department; M, appointing a departmental committee as provided for in these Bylaws; implementation within the department of actions taken by the Executive Committee of the Staff; N. annually reviewing and recommending, as necessary, amendments to the rules and regulations governing the day-to-day operations of the department; O. keeping minutes of all Department meetings to be submitted to the Executive Committee. ARTICLE VII. PEER REVIEW SUBCOMMITTEE: A. Function. The PR Subcommittee reviews and assigns a Peer Review Standard to those cases referred for review.

5 B. Composition. Members include the Department Chair and two Department members in good standing, appointed by the Chair. The three members shall represent three of the Department's surgical subspecialties. C. Duties. 1. review all cases referred for peer review by the QM Department using Surgery Department approved screens and by physicians. 2. review and discuss each case and assign a preliminary Peer Review Standard (PRS). 3. utilize specialists' expertise as necessary for proper evaluation from the department or an external peer reviewer, as indicated. 4. select specific topics/cases to be presented to the Department for discussion. 5. report monthly to the Department Committee. ARTICLE VIII MEETINGS A. The Department of Surgery and Surgery Committee meetings shall be at least quarterly. B. The time and place of meetings shall be determined by resolution of the department or committee. C. Department of Surgery and Surgery Committee meetings (including minimum meeting attendance, establishing a quorum and voting rights) shall be conducted in accordance with the Medical Staff Bylaws. D. The meeting agendas shall be determined by the Chairman of the Department and shall reflect the main functions of the department. ARTICLE IX PRIVILEGES IN THE DEPARTMENT A. Admitting, clinical practice, surgical and temporary privileges shall be granted in accordance with the provisions of the Medical Bylaws and these Rules. B. Core Privileges. 1. Physician members of the Department who demonstrate and/or document current competency and request Core Privileges may be granted and exercise core privileges in the specialty of their board-certification.: 2. The specific privileges and procedures included in the Core for each subspecialty are stated on the Specialty's Privileges checklist. C. Non-Core Privileges Non-core privileges must be specifically requested and require additional specialized supervised training and experience, as described below and/or on the relevant privilege checklist. 1. Robot Assisted Surgery Privileges (Open Procedures and Video Scope Directed Procedures). Eligibility criteria were established by Banner's Robot assisted Surgery Team. Eligibility criteria. (1) Documented or demonstrated current competency in exercising the surgical privileges for the procedure(s) to be performed with computer assistance, and (2) if applicable, documented or demonstrated current competency in for video-scope directed (laparoscopic and/or thorascopic) surgical privileges for the procedure(s) to be performed with computer assistance; and (3) documentation of successful completion of training in computer assisted surgery in residency or fellowship training or through an acceptable course of didactic and hands-on experience in the use of computer assisted surgery. (Training course must be at least eight (8) hours in duration and include at least three (3) hours of personal time on the system during the training AND at least two (2) simulations with team and vendor; and (4) written agreement to participate actively in and comply with the

6 BBMC policies and protocol regarding computer-assisted procedures. Supervision. satisfactory completion of two (2) cases under direct observation with a supervisor who has unsupervised privileges using computer assisted surgery procedures, or an approved proctor in accordance with the current facility supervision/proctoring guidelines/policy. 2. Endoscopic Fundoplication. Eligibility Criteria. Documentation of successful completion of an approved training course. No supervised cases are required. D. Privileges for Members of Surgery and Other Departments. 1. Surgical Assist. A physician wishing to assist in the operating room must show evidence of surgical training during his residency in order to be granted surgical assisting privileges. This requirement includes the specialties of Family Practice, Internal Medicine and Pediatrics. 2. Wound Care Privileges. The Surgery Department/Committee has agreed to provide oversight and grant privileges for wound care physicians. Eligibility. Certification by the American Academy of Wound Management (CWS) or all of the following: a. Board certified (ABMS) in internal medicine, family practice, emergency medicine or surgical specialty (including podiatric surgery). b. Two (2) or more years of experience in wound care. c. Certification in debridements or case documentation of at least 10 debridements in each of the following categories: full, subcutaneous, muscle and bone debridements. d. CME of 10 credits or more per year in wound care related activities. e. Knowledge of advanced wound modalities including use of enzymatics, bioengeered skin substitutes, dressing modalities and diagnostic testing. This can be demonstrated by prior case management or interview with the wound medical director. Core Privileges. Sharp Debridement of wounds (at all levels- down to bone) Local anesthesia Skin Biopsy Skin Graft Bioengineered skin substitute application and management External Skin Expansion application Ultrasonic Debridement Wound Biopsy Incision and Drainage of Abscess Negative Pressure Wound Therapy Total Contact Cast application and management Special Procedures Privileges. Hyperbaric Oxygen Therapy Criteria: Applicant must complete a recognized hyperbaric medicine training program as established by either the American College of Hyperbaric Medicine or the Undersea and Hyperbaric Medical Society (UHMS) with a minimum of 40 hours of training and documented by a certificate of completion OR an equivalent program. 3. Medical Ophthalmology: Physicians applying for medical ophthalmology privileges only shall meet the following qualifications:

7 a) Currently actively practicing Ophthalmology; b) Does not perform surgery. Malpractice insurance as medical ophthalmology status only. c) Not required to take emergency room call. E. Supervision Requirements 1. New Privileges. Any physician seeking initially-granted privileges shall be required to provide the Committee with documentation satisfactory to the Committee, of appropriate training or experience in the performance of this new technique. The committee may request two supervised cases. The Committee reserves the right to omit the supervision requirement in special cases, or to require additional supervised cases when deemed advisable for the patient's welfare, for example. in cases of complexity, ambiguity of prior outcomes. 2. Observation Review: Unless a provisional member s practice raises issues of judgment, competence or professional performance, the exercise of provisional privilege by a member who satisfies the membership requirements will not require observation. Instead, after one year on provisional staff, all provisional staff members will be evaluated by the department to determine to the satisfaction of the medical staff and Board, whether the member has demonstrated the current competence, character, and ethical behavior required for advancement from provisional status. The department may extend a member s provisional status for up to two years. 3. At its discretion, the Department of Surgery Committee may require supervision in a specified number of cases of a given type of any member of the Medical Staff. 4. All supervision reports shall be maintained as confidential pursuant to Arizona Revised Statutes and et. seq. 5. supervisors must possess unobserved privileges in the procedure. F. Privileges New to BBMC. A member of the Department of Surgery who wishes to introduce a diagnostic or therapeutic procedure and/or technique that is new to the Hospital and/or the Medical Staff shall apply for an interview with the Surgery Committee and present data in support of the need, efficacy and safety of the procedure and/or technique and his training and qualifications to perform such procedure and/or technique. The Committee shall take appropriate action in a reasonable period of time. If the action is deemed inappropriate by the applicant, he may request that hearing procedures be initiated as provided in the Medical Staff Bylaws. ARTICLE X AMENDMENTS A. Policy. The Department Committee will annually review and update at least bi-annually these Rules and Regulations so that its provisions describing department, committee and chair functions and responsibilities; privileges, membership and privileging criteria; and member responsibilities are current and do not conflict with the Bylaws or the Staff Rules and Regulations. B. Process. 1. amendments may be recommended by any Department member or Medical Staff Committee; 2. at least bi-annually, the Department Committee shall forward its entire Rules and Regulations with any proposed amendments to the Bylaws Committee for its review for consistency with Medical Staff bylaws, general rules, and legal requirements; 3. to become effective, the Department's rules are subject to approval by the Executive Committee, the General Staff, and the Board.

8 ARTICLE XI GENERAL RULES AND REGULATIONS A. Surgical Assisting. 1. The surgeon of record shall determine whether or not an assistant is necessary, regardless of whether a case is considered a major or minor procedure, and this includes assistants for laparoscopic cholecystectomy procedures. 2. A non-physician assisting in surgery must be approved by the Committee. If such an assistant is present, the operative surgeon is required to remain in the room throughout the entire procedure. 3. The qualifications of the appropriately credentialed assistant are at the discretion of the surgeon, taking into consideration his/her opinion of the best interests of the patient, the wishes of the patient and the opinion of the referring physician. B. Pathology Exam.. All tissues removed by biopsy or at operation anywhere in the Hospital shall be sent to the Hospital Pathology Department accompanied by pertinent clinical information. The Pathology Department will determine the extent of examination required. A written report of each examination shall be entered in the patient's chart. The specimens exempted from this requirement shall be determined by the Pathology Department and shall include breast implants, cataracts, debridement tissue from acute trauma, foreskin from infant circumcisions, placentas unless exam ordered by the attending physician, prosthesis which will include orthopedic hardware, scar tissue removed for cosmetic reasons, septoplasty specimens/nasal cartilage, skin from blepharoplasty, skin removed for cosmesis or panniculus specimens, trim tissue from a bowel resection and extra fat, stents, implants, and foreign bodies such as bullets, synthetic vascular grafts and rib segments removed for operative access, teeth and toenails. C. Consultation 1. In major surgical cases in which the patient is not a good risk, and in all cases in which the diagnosis is obscure or when there is doubt as to the best therapeutic measures to be utilized, consultation is appropriate. Obviously, judgment as to the serious nature of the illness and the question of doubt as to diagnosis and treatment rests with the physician responsible for the care of the patient. A consultant must be well qualified to give an opinion in the field in which it is sought. 2. A satisfactory consultation includes examination of the patient and the record and a written opinion signed by the consultant which is part of the record. When operative procedures are involved, the consultation note, except in emergency, shall be recorded prior to operation. Approved by the Governing Board: May 14, 2015